Provider Demographics
NPI:1508058249
Name:WHITE MOUNTAIN FOOT AND ANKLE CARE CENTER PLLC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN FOOT AND ANKLE CARE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:H RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-367-3701
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0039
Mailing Address - Country:US
Mailing Address - Phone:928-532-1122
Mailing Address - Fax:928-532-1124
Practice Address - Street 1:5448 WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5739
Practice Address - Country:US
Practice Address - Phone:928-532-1122
Practice Address - Fax:928-532-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ640213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ087223Medicaid
AZV09636Medicare UPIN